The Weekly Reflektion 52/2022

Labour shortages led to the bridge crew of the Helge Ingstad being less experienced than was the norm, but the job had not got any easier.

Helge Ingstad almost submerged after collision

Were the bridge crew on Helge Ingstad negligent, or did the Norwegian Navy set them up to fail?

This is the second Reflektion focussed on the incident on 8th November 2018 when the Norwegian Royal Navy frigate Helge Ingstad was in collision with an oil tanker, the Sola TS in Hjeltefjord near Bergen in Norway. The collision tore a 45 m long hole in the hull of the frigate while the Sola TS suffered only minor damage. 

At 03:40 hrs the Helge Ingstad was travelling south along the fjord, 7 nautical miles north of the Sture oil terminal, while the tanker Sola TS was just leaving the terminal travelling north. It was Norwegian Navy normal practice to sail with the Marine Automatic Identification System (AIS) in passive mode, meaning other vessels could not identify the vessel automatically. All vessels of over 300 gross tons are required to use AIS as an aid to avoid collisions at sea, but military vessels are exempt from this requirement. Fedje Vessel Traffic Service (VTS) who were responsible for coordinating traffic in the area, were informed of the voyage plan.

Between 03:45 hrs and 03:53 hrs, the Officer of the Watch (OOW) shift handover took place on Helge Ingstad. The focus for the handover was three vessels travelling northwards up the fjord, in addition to some discussion concerning a ‘floodlit object’ on or close to shore. Both OOW’s agreed that it was either a floodlit quay, or a fish farm, and the AIS reading showed a stationary object according to post-collision interviews. This discussion established a mental model for the OOW and bridge crew for the early part of the shift. The ‘floodlit object’ was, in fact, the tanker Sola TS just leaving the Sture Terminal.

The bridge crew was five persons, the OOW, the assistant to the OOW, and a three-man bridge watch team. In addition, two trainees were present on the bridge. The average age of the bridge team was 22,4 years as there is a shortage of qualified navigators to man the frigates, and four of the five bridge team were conscripts. An OOW normally has two to four years’ experience however the OOW on duty had only 9 months training, followed by 8 months operational experience on Helge Ingstad, some of this at sea. Due to labour shortages, the OOW had been given the position sooner than previously would have been the case. The training of the two trainees on the bridge was focused on optical navigation, and obviously took time and attention away from the normal tasks of the bridge crew.

At 03:57 hrs, Sola TS asked Fedje VTS for the identity of the vessel travelling southwards as it had no AIS identification. Fedje claimed it did not know, although they had been informed of the Helge Ingstad’s voyage plan. Separation at this time was 2720 m. Sola TS used an Aldis lamp to signal to the unknown vessel, however received no response. The Helge Ingstad could not see the signal flashes due to deck lights shining brightly on Sola TS, which also made the navigation lights almost invisible. Helge Ingstad still thought the floodlit object was stationary near to the shore, but registered that it was closer than expected, and adjusted the rudder 10o to port (left) to maintain a safe distance. Sola TS took what they considered to be evasive action by steering 10o to starboard (right) so that the ‘unknown’ vessel could pass to port, between the SOLA TS and shore. The OOW on Helge Ingstad still thought the floodlit object was stationary and either on or next to the shore and therefore passing between the object and shore would be impossible.

Fedje VTS suddenly remembered that the vessel could be the Helge Ingstad and informed Sola TS by VHF radio. The OOW on Helge Ingstad heard this conversation on the VHF radio and started listening to the transmission. Separation was now 875 m. Sola TS told Helge Ingstad to turn to starboard immediately, but the OOW thought that he was talking to one of the other vessels travelling northwards further out in the fjord. The OOW informed on the radio he could not turn to starboard because of the floodlit object, still unaware that this was the Sola TS.

Sola TS again told the Helge Ingstad to turn hard to starboard, and the OOW said he would do so once he had passed the floodlit object. At 04:00:27 the separation was 500 m. Sola TS realising a collision was becoming inevitable stopped all engines and pleaded with Helge Ingstad to do something. At 04:00:44 separation was 250 m. Helge Ingstad now realised that the floodlit object was a vessel on collision course, and as Sola TS put engines full astern, the OOW attempted to manoeuvre past the bow of Sola TS. The starboard anchor of Sola TS hit the starboard side of Helge Ingstad tearing a 40 m hole in the side.

The investigation team criticised the Norwegian Navy for sailing with the AIS system in passive mode. As noted, military vessels are exempted for the compulsory use of the AIS, however operating without the AIS demands ‘special vigilance’ according to the regulations. The Navy has no requirements for implementing special mitigating measures when using AIS in passive mode, even though the collision risk is inevitably higher.

The Commanding Officer (CO) is solely responsible for determining whether an OOW together with the bridge crew are competent. The young average age and lack of experience of the bridge crew, together with additional tasks of training personnel contributed to the incident. Research has shown that situational awareness is affected by experience and expertise, and that less experienced people have less capacity than experienced people for picking up weak signals. The more that people have experienced similar situations, the easier they can realise when things are not right (the recognition effect).

A DnV survey of safety culture in the Norwegian Navy from 2016 concluded that “there seems to be an increasing tendency to clear personnel sooner than used to be the case.” In addition, the culture “is characterised by a fundamental assumption of being in ‘full control’. This can result in a lack of cooperation and involvement during operations. It entails that individuals will tend to be overconfident in others doing everything right, which is hardly realistic.”

The Norwegian Attorney General decided to charge the inexperienced OOW with negligence which is perhaps directed at the wrong level of management in the Navy. He was judged competent by his CO although significantly short of the experience expected in the recent past. He was given additional tasks diverting his full attention to the job in hand. The lack of mitigating measures when sailing with AIS in passive mode, with a young bridge crew is not the fault of a single OOW, but a systemic failure in the Navy. The decisions taken by the OOW would probably not be different to those taken by a another OOW with the same experience and in a similar situation.

Blaming the OOW seems the easy way out for the Norwegian Navy and avoids pointing the finger at the people responsible for the systems the Navy has in place. Attributing the blame to human error and punishing the person(s) involved is not likely to lead to any improvements that will prevent this type of incident happening again. Systemic failures need a deeper understanding of the issues rather than targeting individuals who happen to be involved on this occasion.

The lack of trained and experienced personnel is not just a challenge for the Norwegian Navy. The demographics of the petroleum industry indicate that there will be a significant shortage over the next 5 – 10 years. Will the industry have the patience to tailor the activities and workload to the people available or will the industry resort to the Norwegian Navy approach and give people responsibilities that they are not able to take on?

Reflekt AS